Clinicians Ordering Oxygen and Oxygen Equipment - Reference Guide - JA DME

The following contains tips for physicians and non-physician practitioners concerning Medicare's coverage of Oxygen and Oxygen Equipment.

• For Medicare to consider coverage of oxygen and oxygen equipment, beneficiary must have a severe lung disease, such as COPD or cystic fibrosis, or hypoxia-related symptoms corresponding to a condition that might be expected to improve with oxygen therapy (examples (not all-inclusive) such as recurring CHF due to chronic cor pulmonale or pulmonary hypertension)
  • Beneficiary's medical record must document disease and show condition's progression and need for oxygen therapy
• Beneficiary has had a qualifying blood gas study, which can be either an oximetry test or an arterial blood gas test
  • This information must be in beneficiary's medical record and values must correspond to information on CMN (CMNs required for dates of service prior to January 1, 2023 only)
• Blood gas study can be administered while beneficiary is awake or asleep (under certain circumstances)
  • Outpatient testing must be done while beneficiary is in a chronic stable state and not during a period of acute illness or exacerbation of underlying condition or disease. Medicare will also consider a blood gas study done within two days of discharge from a hospital. Medicare will consider coverage for both stationary and portable oxygen systems if blood gas study is done while beneficiary is awake or during exercise. Portable oxygen systems are not eligible for coverage if qualifying blood gas test is performed during sleep (i.e., an overnight oximetry test)
• Other alternative treatments have been tried or considered and deemed clinically ineffective
  • Beneficiary's medical record must show what other treatments have been used or considered and why oxygen therapy is next medically necessary step in treating his/her condition
• There must be a provider encounter with beneficiary and a qualifying blood gas study taken within 30 days of initial need for oxygen therapy
  • This is a requirement found in Local Coverage Determination (LCD) that physicians and suppliers must abide by
• For dates of service prior to January 1, 2023 only, Physician or non-physician practitioner must complete, sign, and date an Oxygen Certificate of Medical Necessity (CMN), CMS Form 484, before company providing oxygen equipment can file oxygen claims to Medicare program
  • Use of CMN is a CMS requirement. Physician must sign and date Section D of CMN, but a staff member may complete Section B. Durable Medical Equipment (DME) supplier will complete Sections A and C – usually before sending it to physician's office. Completing CMN in a timely manner will allow DME supplier to submit claims to Medicare

These facts do not encompass all guidelines surrounding oxygen and oxygen equipment but provide a quick overview of the LCD requirements. Medical professionals ordering oxygen should review the Oxygen and Oxygen Equipment LCD found on one of the DME Medicare Administrative Contractor (MAC) websites.

• Jurisdiction A (CT, DE, MA, ME, MD, NH, NH, NY, PA, RI, VT, District of Columbia)
  • Clinician's Corner
• Jurisdiction B (IL, IN, KY, MI, MN, OH, WI)
  • Physician's Corner
• Jurisdiction C (AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX, VA, WV, Puerto Rico, U.S. Virgin Islands)
  • Physician's Corner
• Jurisdiction D (AK, AZ, CA, HI, ID, IA, KS, MO, MT, NE, NV, ND, OR, SD, UT, WA, WY, American Samoa, Guam, Northern Mariana Islands)
  • Clinician's Corner
• Jurisdiction B (IL, IN, KY, MI, MN, OH, WI) and DME MAC Jurisdiction C (AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX, VA, WV, Puerto Rico, U.S. Virgin Islands)
  • Physician's Corner